PAIN ASSESSMENT

PURPOSE  To provide guidelines for the appropriate identification and assessment of patients who may experience pain

POLICY  All patients will receive pain assessments. When pain is identified, a more comprehensive pain assessment will be completed when warranted by the patient’s condition. Pain assessment will be documented to facilitate regular reassessment and follow-up by clinicians

PROCEDURE  During the initial assessment and on an ongoing basis, the patient will be asked a general screening question regarding current or recent pain as part of the baseline data. Clinicians will consider the patient’s personal, cultural, spiritual, and ethnic beliefs when assessing pain or discomfort  When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible :

PROCEDURE CONTINUED  Pain intensity using a rating scale (0-10)  0 = no pain  10 = unbearable pain  Pain intensity should include current pain, worst pain, and least pain using the scale. The patient will be reassessed every visit for the existence and intensity of pain and the effectiveness of interventions to relieve pain

PROCEDURE CONTINUED  Pain location  Pain quality, patterns of radiation, and character. Use the patient’s own words whenever possible  Pain onset, duration, variations, and patterns  Alleviating and aggravating factors  Present pain management regimen and effectiveness  Pain management history, to include a medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, and manner of expressing pain

PROCEDURE CONTINUED  The PATIENT’S pain goal, including pain intensity and goals related to function, activities, and quality of life  Physical exam or observation of the site of pain  Secondary symptoms related to pain such as nausea, vomiting, respiratory distress, or nutritional compromise

PROCEDURE CONTINUED  If the patient is unable to communicate pain using the numerical rating scale or is cognitively impaired, the clinician will assess behavioral factors that signal pain or discomfort and include this information in either the Pain Ad assessment or clinical narrative note  Pain assessments will be part of the comprehensive assessment and will be updated if significant changes occur.

PAIN MANAGEMENT  The patient’s preferences for pain management will be reflected in the pain control measures selected  Non-pharmacological interventions will be considered for the treatment of pain  Common side effects of analgesic medications will be anticipated, and preventive measures will be implemented  Patient and family/caregiver education will focus on the use and side effects of analgesic and/or adjuvant medications, expected responses to therapy, and the importance of administering medications according to prescribed dosage and frequency